What are the different techniques for cheiloplasty (lip surgery)?

Cheiloplasty Techniques for Lip Surgery

The primary techniques for cheiloplasty include rotation-advancement flaps (Millard technique), triangular flaps (Tennison-Randall), straight-line repairs, and geometric techniques like Meara's cheiloplasty for isolated clefts, with the choice depending on cleft severity, gap width, and whether the defect is unilateral or bilateral. 1, 2

Primary Techniques for Cleft Lip Repair

Rotation-Advancement Flaps

• This is the most commonly used technique for unilateral cleft lip repair, involving rotation of the medial lip segment and advancement of the lateral segment to close the defect 1
• Best suited for moderate to severe cleft gaps where significant tissue mobilization is required 1
• Often combined with primary rhinoplasty to address nasal asymmetry at the same surgical session 1

Meara's Cheiloplasty

• Specifically designed for isolated cleft lip or cases where the gap between labial segments is not wide 1
• Produces less aggressive geometric flaps compared to traditional rotation-advancement techniques 1
• Average surgical duration is approximately 85 minutes with excellent aesthetic outcomes including symmetrical lip height and well-balanced nasal appearance 1
• Results in more harmonic lip contours with less undulation compared to other geometric techniques 1

Triangular and Quadrangular Flap Techniques

• Traditional geometric approaches (Tennison-Randall) used for more severe cleft presentations 1
• Create more angular, geometric incision patterns to redistribute tissue 1

Specialized Techniques for Complex Cases

Bilateral Cleft Lip with Premaxillary Protrusion

• Simultaneous premaxillary repositioning and cheiloplasty can be performed in a single stage for adult patients with unrepaired bilateral cleft lip and palate 2
• This combined approach achieves appropriate premaxillary positioning without risk of avascular necrosis when properly executed 2
• Particularly valuable for adult patients with previously unrepaired or poorly repaired bilateral clefts 2

Augmentation Cheiloplasty

• Utilizes advancement of two triangular distally-based flaps in a V-to-Y technique 3
• Incorporates plication of the orbicularis oris muscle to enhance lip thickness and projection 3
• Produces inconspicuous scars with minimal complications 3
• Indicated for thin lips requiring volume enhancement rather than cleft repair 3

Modiolar Rotational Cheiloplasty

• Specialized technique for facial paralysis affecting the central oval of the face 4
• Involves alar and oral commissure repositioning via modiolar rotation with alar base transposition 4
• May include concomitant wedge resection for patients with significant atrophy and lateral displacement of the lower lip 4
• Provides both functional improvements (reduced drooling, buccal stasis, dysarthria, nasal obstruction) and aesthetic enhancement 4

Surgical Timing and Approach Algorithm

Primary Repair

• Perform primary cheiloplasty at approximately 6 months of age (range 5-12 months) for optimal results 1
• Initiate oral feeding 4 hours post-procedure, but withhold bottle-feeding for 2 weeks postoperatively 1

Secondary Corrections

• Secondary cheiloplasties are often required despite optimal primary repair, particularly in bilateral clefts 5
• Timing is typically at school entry age, driven by psychological impact on the child 5
• Frequently combined with alveoloplasty (GPVP - alveolar transplantation with vestibulo and labio-plastie) 5

Critical Technical Considerations

Technique Selection Based on Cleft Severity

• For isolated cleft lip without cleft alveolus: Use Meara's cheiloplasty for shorter operative time and superior aesthetic outcomes 1
• For moderate to severe gaps: Employ rotation-advancement or geometric flap techniques 1
• For bilateral clefts in adults: Consider single-stage premaxillary repositioning with simultaneous lip repair 2

Common Pitfalls to Avoid

• Avoid using aggressive geometric techniques for minor clefts where simpler approaches like Meara's would suffice 1
• Do not overlook the need for simultaneous rhinoplasty when nasal asymmetry is present 1
• Be prepared to manage lip scar retraction with triamcinolone infiltration if it occurs 1
• Ensure adequate orbicularis muscle reconstruction to maintain lip function and contour 3

Postoperative Management

• Monitor for complications including scar retraction, asymmetry, and functional deficits 1
• Plan for potential secondary revisions, as residual imperfections are common even after optimal primary repair 5